Provider Demographics
NPI:1003150384
Name:TAGATAC, MARELLA JO (DDS)
Entity type:Individual
Prefix:DR
First Name:MARELLA
Middle Name:JO
Last Name:TAGATAC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 MOLINETTO ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-3048
Mailing Address - Country:US
Mailing Address - Phone:858-354-6854
Mailing Address - Fax:
Practice Address - Street 1:8995 W FLAMINGO RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-0441
Practice Address - Country:US
Practice Address - Phone:725-677-1164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284491223G0001X
NV7046122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice